A nurse is caring for a patient immediately following endotracheal intubation.
Which of the following actions should the nurse prioritize to assess the patient for complications?
Auscultate lungs for the presence of breath sounds.
Determine that the pulse oximetry is greater than 95%.
Assess baseline level of consciousness.
Assess for the presence of circumoral cyanosis.
The Correct Answer is A
Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While medication errors are indeed considered adverse events, this statement does not fully capture the scope of patient safety and prevention of harm.
Choice B rationale
Errors of execution are usually unintentional, not intentional. They often occur due to system failures rather than time or resource constraints.
Choice C rationale
It is estimated that as many as 90% of medication errors are preventable. This highlights the importance of safety measures and protocols in healthcare settings to prevent harm to patients.
Choice D rationale
Poorly coordinated care and nosocomial infections are examples of errors, but they represent only a fraction of the potential safety issues in healthcare.
Correct Answer is B
Explanation
Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
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